A nurse palpates a client's radial pulses bilaterally and notes the client's right radial pulse is bounding, and the client's left radial pulse is as expected. The client's heart rate is 80/min. Which of the following documentations should the nurse make?

Right radial pulse 4+, 80/min, palpated

Left radial pulse 1+, 80/min, palpated

Left radial pulse 4+, 80/min, palpated

Right radial pulse 2+, 80/min, palpated

Answer and Explanation

The Correct Answer is A

A. Right radial pulse 4+, 80/min, palpated:
A 4+ pulse is bounding, which is consistent with the nurse’s finding. HR is documented as 80 bpm.

B. Left radial pulse 1+, 80/min, palpated:
There is no indication that the left pulse is weak or thready (which would be 1+).

C. Left radial pulse 4+, 80/min, palpated:
The left radial pulse was described as expected, not bounding.

D. Right radial pulse 2+, 80/min, palpated:
A 2+ pulse is considered normal, but the right pulse was bounding, which corresponds to a 4+ rating.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Explanation

Finding	Assessment	Rationale
Temperature: 38.6°C	Worsened	The temperature increased from 38.2°C to 38.6°C, suggesting worsening fever or infection.
Pulse oximetry: 95% on 40% O₂	Improved	The client’s oxygen saturation increased from 85% to 95%, though with supplemental O₂, showing improved oxygenation.
Respiratory rate: 22/min	Improved	RR decreased from 32 to 22, indicating better respiratory effort and less distress.
Blood pressure: 112/54 mmHg	Unchanged	Minimal change from 114/56 to 112/54; both readings are within similar ranges.
Mucous membrane color: pink	Improved	Pink mucous membranes indicate improved oxygenation and perfusion, compared to pale earlier.

A. T 38° C (100.4)°F, oral B. BP 106/60 mm Hg, supine C. HR 99/min D. R 20/min E. Pulse oximetry 95% on room air

Correct Answer is ["A","B","C","D","E"]

Explanation

T 38°C (100.4°F), oral
The temperature has decreased from 38.9°C to 38.0°C, showing improvement in fever, likely due to rehydration and reduced systemic inflammation.

BP 106/60 mm Hg, supine
Blood pressure has improved from a hypotensive state (88/56) to a more stable reading, indicating effective fluid resuscitation.

HR 99/min
Heart rate decreased from 112/min to 99/min, indicating reduced compensatory tachycardia, likely due to improved fluid volume status.

R 20/min
Respiratory rate is within normal limits and stable; no signs of respiratory compromise.

Pulse oximetry 95% on room air
Oxygen saturation is maintained within normal range without supplemental oxygen, indicating adequate perfusion and oxygenation.

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A nurse palpates a client's radial pulses bilaterally and notes the client's right radial pulse is bounding, and the client's left radial pulse is as expected. The client's heart rate is 80/min. Which of the following documentations should the nurse make?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client. Exhibits For each finding at 1100, click to specify if the finding indicates that the client's condition has improved, worsened, or is unchanged.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Explanation

A nurse is assisting in the care of a client. Exhibits Click to highlight the findings that indicate the interventions were effective. To deselect a finding, click on the finding again. T 38° C (100.4)°F, oral. BP 106/60 mm Hg, supine HR 99/min R 20/min Pulse oximetry 95% on room air

Correct Answer is ["A","B","C","D","E"]

Explanation

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